Visiting Nurse Association

An Interview with James C. Summerfelt, M.Ed, MSPT, President and CEO of the Visiting Nurse Association of Omaha
By Rick Buckingham and Steve Gedwillo, Creighton University MBA students

Every year, the Better Business Bureau awards those companies that embody ethics and integrity. It comes as no surprise that the Visiting Nurse Association would be a BBB Integrity Award winner. Mr. James Summerfelt is the President and CEO of the Visiting Nurse Association of Omaha. He grew up in Chicago with what he describes as “Midwest values” and began his career as a physical therapist. Mr. Summerfelt has always been interested in serving those who do not have the same access to services as others. In an industry which is plagued by a for-profit mentality, Mr. Summerfelt commands an organization which deliberately caters to those who cannot pay. His strong, ethical foundation serves as an example for businesses, for- profit and nonprofit alike. The following responses are quotes from an interview with Mr. Summerfelt on October 14, 2010.

Please tell us about the Visiting Nurse Association (VNA) and about the Integrity Award.

The VNA started on the East Coast, but we are surprisingly one of the oldest VNAs in the country. 1896 is when it was founded to take care of people regardless of their ability to pay. On the frontier, as it was then, you had to make it on your own, or you didn’t make it. Mortality, in general, and infant mortality, was high. There weren’t nonprofit, safety net organizations to take care of you if you were stumbling and ready to fall. This band of nurses, looking like military almost, was fighting a war on misery. They were literally walking on the streets, knocking on doors, checking on people to see if they were healthy.

The Integrity Award was an honor for this organization to get. We are owned by the community. Our board of directors is made of volunteers from the community. We have done things for the right reasons since the inception, and we still do that even with the changing landscape that we’ve had over the course of time.

“Providing healthcare to get a margin, to make money,was illogical.”

Give us a history of how you came to the VNA, and tell us a little bit about your ethical foundations.

Growing up in Chicago helped me and my family with developing work ethics. You have to work hard. You get what you earn. There are no free lunches. We went to church. My mother was a big influence on doing things for the right reason and not because you’d be punished if you didn’t. It was just the right thing to do.

I went to undergraduate at Northwestern, and I got into healthcare through physical therapy. I worked at the VNA in Chicago as a physical therapist. I grew up in Chicago in the suburbs, but I was attracted to working in the inner city when I graduated from PT school. It would have been easy to work in the suburbs, but I was somewhat challenged by an area where it was difficult to staff and no one wanted to work there. I started working on the south side of Chicago in housing

projects. As you get experienced in what you do, you want to be challenged. Working in an area with limited resources provided an added challenge.

I went on to work for a large, for-profit, publicly-traded company. Providing healthcare to get a margin, to make money, was illogical. It was a contradiction that I could never deal with. I went out to Reno, Nevada, to work for a faith-based hospital and ran their home care and hospice agency and started to get into hospital administration. My love really was community health, and I learned that very quickly. At that time, the CEO of the VNA in Omaha was retiring. They were doing a national search, so I applied and, fortunately, was chosen. It was a nice 360 degrees. I started off with the VNA in Chicago as a staff physical therapist and then becoming the CEO of this organization. I also have participated in the American Physical Therapy Association, a professional organization, as well as the VNA of America, a trade organization.

Please give us an idea of what ethics means to you.

It is doing things for the right reason. It’s your morals that guide what you do each and every day.

As the leader of this organization, I try to run it the same way that I run my own life. My mother taught me to always tell the truth. That way, you don’t have to remember what you said. Anything and everything that you do, if it was smack dab on the front page of the paper, would you be proud of it, or would you say, “Oh, I’m sorry we did that?”

It is having the highest of morals, doing things for the right reason, looking out for your fellow man and being proud of what you’re doing.

Would you say that company ethics comes from the top down? How is ethics infused into your company?

I believe in leading by example: work hard, play hard and have a good work-life balance. The board of directors sets the vision and the mission, as well as the values for the organization and then they hone them down to “what are the goals?” The vision of the organization is to assist the community to be as healthy as possible. The mission is to do this regardless of people’s ability to pay or their complexity of care. Someday, we want to have the healthiest community possible, and we’re going to do that regardless of people’s ability to pay and the complexity of their conditions.

It does start with the leader. They have to demonstrate that they have the highest ethics and morals and values, or everyone will see through it. There has to be consistency through the organization. The values are what guide our decisions. The leader of the organization has to be the leader of delivering that message. If the leader of any organization doesn’t subscribe to that or can’t stand behind any of that, the whole organization is going to falter and not be as effective as possible.

How do you approach ethics on a corporate level?

At the corporate level, you have to be competitive. You can’t be passive, in this day and age, because we are a business. Even as a nonprofit, or rather a community benefit organization, we have to do well as an organization in order to do good out in the community. We have to be proactive and aggressive, but not abusive of the system. There’s a lot of unethical fraud and abuse going on in the billing for the type of business that we do today.

The government has changed the reimbursement methodology for what we do probably five times in the last seven years. At first, they reimbursed you for your costs. People took advantage of that and piled on costs that weren’t there. They would hire all their family members, and everyone would be on the payroll. They figured out the loopholes.

The current payment methodology is episodic payment. For every patient we see, we go through an elaborate assessment in three different areas: the amount of service they need, how they’re functioning, and their clinical diagnosis. So someone can figure out how to gain a maximum reimbursement depending upon how you code these things. As elaborate as the government has made it, there are still people out there that can figure how to work around that.

Being the safety net for the community, we end up getting a patient mix that isn’t as lucrative as if you were just in it for the profit. Sometimes we know we’re going to lose money when we take a case. We don’t have any competition for that. The purpose of nonprofit organizations like ours is to take care of the sector that no one can make money on.

Tell us about an ethical situation that was relatively easy.

The simple ones are people who lie or falsify time records. That’s pretty black and white. Do you overlook that? No, you can’t overlook that. We are giving people patients’ addresses and diagnoses and saying, “Here, go treat this person,” and they go off by themselves, and they do the right thing. We have to have a strong infrastructure. We have to have strong values of the organization when we’re hiring people, because we trust them to go out into people’s homes and not rob them blind. Those are the easy things, when it is reported to us and we can identify that someone says they did something that they, in fact, didn’t do.

“Sometimes we know we’re going to lose money when we take a case. We don’t have any competition for that.”

Could you elaborate on how you search for ethical individuals to work for you?

Our recruiting process is largely based on referrals from current employees. One of our goals is to attract and hire the very best people. The three areas we really look at are attitude, skills set and knowledge. It’s that attitude and what they believe that is the most important. You can help people get more experience to increase their skills, and you can give them things to read to increase their knowledge, but your attitude is something that you’re born with or you’re raised with and taught early on in life. It’s difficult if not impossible to turn that around.

Other than a background check, we don’t use any other screening tools in our process. We have a recruiter who screens them initially. The recruits go through a series of interviews with a lot of different people to gain a 360 perspective. It’s not just one person’s perspective that we use to hire. It’s a group process.

Can you describe a contrasting ethical situation that was difficult to deal with?

All situations, difficult or easy, you go back to trying to imagine how everyone would view what you’re doing. It’s not just your initial reaction and solution to that problem, because you’re probably relying on your personal ethics. Someone else might have a different perception or perspective on that. The way we manage this organization is somewhat of a group process to make sure that we get a lot of input. It’s not just one person’s decision.

Hard ones are more with the end-of-life care. End-of-life care does present itself with some very difficult choices. There are some cases where there isn’t a wrong answer. You have to take into consideration the patient’s wishes and desires and the family’s wishes and desires. That’s why hospice really is a different animal. It’s a team, and the team involves the patient and the family as well. Healthcare is becoming less just the physician making all the shots and having all the answers. It is becoming more interdisciplinary, including the patient and the family.

In hospice, we have had to sit down with our ethics committee and present the case. Are we making the right decision? Whether it be with pain medication or the patient requests something and the family doesn’t want that or the other way around. The team then looks at that and discusses it. The physician, the nurse, the pharmacist, all the disciplines talk it over, look at it from every which way and take all considerations. We have a group process decision-making solution that includes the patient and the family.

What do you think are the key values that come into play in making that decision?

It’s the quality of life. That’s where function is paramount. People identify what quality means to them. If they have to go through a course of treatment that is very painful or uncomfortable, they ask, “What is the return on that investment?” Our hospice team is very good at saying, “You can do that, and maybe you’ll extend your life another month. Is that worth going through all the pain and discomfort or would you rather receive some pain medication and be out of pain and be able to enjoy what time you’ve got remaining?” Hospice really is helping people function maximally at the end of their life. Those are extremely ethically, morally tough decisions.

Is that ultimately the patient’s decision?

Exactly. It’s tough because sometimes they just say, “I’m done with this. I’m tired, I don’t want to do anymore,” and the family says, “Oh, you’ve got to, we don’t want to lose you, you’ve got to do everything possible to hang in here.” This is where our professionals can step in and counsel the family and the patients to make the right decision.

Does Omaha have a different approach to ethics? Is there something special here? What do you think are typical Omaha values?

In Omaha, people are looking out for each other, and they actually walk the talk. They do outwardly care for each other. You see it on the streets. You see it when we do fundraising. It’s something that has either been handed down, or it’s just inherent in this community. A lot of the different services we provide are funded through donations and contributions. There are other VNAs throughout the country that don’t have the opportunity to get funding from the community to provide those services, so they have had to cease those services.

I knew very little about Omaha when I moved here. Out west, in comparison, people were very self-centered. They bought everything they could, maximized their credit cards to buy big houses and fancy cars. You physically notice that when you leave a city out west and you come to the Midwest. You see a lot more normal cars versus the Lexus, Mercedes, or BMWs. It’s a reflection of where people’s values are and

This depiction of the VNA’s early days greets visitors as they walk into the VNA’s building where they put their resources. They put them toward taking care of each other out here.

What gets you up in the morning? What do you like about coming to work?

Every day is a challenge. I go to Washington at least eight times a year and meet with both Nebraska and Iowa legislators there. I’m pretty well known in all their offices. It’s fun, because I have continued to challenge myself. I don’t get bored. If I get comfortable, I get bored. Everything is always changing, and change is good. I look for the silver lining in everything I do.

What are the biggest ethical challenges for young business professionals today, and what tips would you give them?

There are a lot of unethical businesses out there that may attract people because of high compensation. I would warn people to ask questions. An interview is not just the employer asking the questions of the prospective employee. The prospective employee needs to ask those questions of the employer to make sure they are someone they really want to work for. It’s not just about the compensation. That should really be the last thing you look at. They should ask some ethical questions of the employer and dig into the mind of the company. The working environment is almost like marriage; it’s a long-term commitment. Who you associate with is a reflection of yourself. My advice is to make sure you know who you are going to be related to when you’re working.